Bariatric Surgery In Teens—A Narrow Window Of Opportunity

Waiting too long to consider weight-loss surgery could mean the patient remains obese even after surgery

A recent study evaluating clinical characteristics of teens who have undergone laparoscopic Roux-en-Y gastric bypass surgery from 2002 until 2007, doctors may have a much narrower window of opportunity to reverse morbid obesity in teens than originally realized, a recent article reports.

Conducted at Cincinnati Children's Hospital Medical Center and published in the current online edition of the Journal of Pediatrics, the study focused on 61 teens who underwent laparoscopic Roux-en-Y gastric bypass at Cincinnati Children's.

One year after the study, BMI in the overall group of teens pre-surgery decreased by 37 percent. However, because of their high starting weights, the teens were still considered morbidly obese, meaning doctors can predict what a patients weight will be one-year after bariatric surgery.

"Current guidelines for adolescent weight loss surgery suggest that we begin to consider surgery only after a teen is 80-100 percent overweight,” says lead author of the study Thomas Inge, MD, PhD, Associate Professor of Surgery and Pediatrics.” Our new data show that when we intervene when a patient is between 100 and 150 percent over ideal weight, we can expect successfully resolution of obesity. But by the time the teen is 200 percent over their ideal weight for age, the surgery will reduce their weight substantially, but many of the patients will still remain morbidly obese.”

According to the article, this is the first study of adolescents to specifically show that the post-operative weight of a patient is strongly influenced by the starting weight. This raises a concern that waiting until children are “super obese” is too long. Surgery may result in major weight loss, but it does not resolve the problem of obesity and the medical problems associated with it. Meanwhile, intervening at an early stage of the disease may have a better outcome.

For example, the article details how patients who remain significantly obese even after surgery surgery, this excess weight can have negative effects on joints and mobility. Meanwhile, the long-term risks of remaining seriously overweight are unknown.

According to co-author Dr. Stavra Xanthakos, Assistant Professor of Pediatrics and pediatric gastroenterologist, "We doctors have to do a better job of identifying teens who are gaining enormous amounts of weight quickly and get help for them earlier."

Dr. Xanthakos says that when doctors or parents notice that a teen is beginning to gain weight rapidly, there should be a staged approach to managing the weight problem.

"If the weight gain is not effectively stopped with initial nutritional or exercise measures, then even more intensive treatments or programs are indicated, and ultimately some very serious thought has to be given to surgery," said Dr. Xanthakos.

Mary L. Brandt, MD, Professor and Vice Chair of the Michael E. DeBakey Department of Surgery and a pediatric surgeon at Texas Children's Hospital says she’s concerned about these results as well.

"We are trying to help teenagers who are at high risk for preventable but life-threatening diseases such as diabetes or obesity induced liver disease. Bariatric surgery will improve the medical condition of obese teenagers regardless of the starting weight of the patient,” she says. “But our ability to help these children prevent or reverse their life-threatening diseases will be even greater if our patients are able to approach a normal weight."

According to Brandt, "The other major implication of this new data is that many insurance companies will delay surgery for years, usually by requiring documentation of multiple attempts at weight loss. Severely obese teenagers only rarely respond to these kinds of treatments and, despite intense efforts to lose weight, often will gain weight during these efforts. Although it is ethically important for these children to have a least one well supervised attempt to lose weight without surgery, this report shows us that delaying the surgery while trying multiple times may not be in their best interest."

Similar to previous studies, this research concluded that patients generally show significant improvement or resolution of cardiovascular risk factors such as blood pressure, cholesterol, and triglyceride levels.

According to Dr. Inge, these findings indicate that families and communities need to take childhood weight problems seriously and aggressively pursue the best treatment options available for them before the weight problem gets out of hand.

"As doctors who take care of kids, we have an obligation to identify those patients who are at highest risk and start explaining treatment options to families earlier before the child or teen gets to be two or three times his or her ideal weight, " she said.